STDs among Sexually Active Female College Students: Does Sexual Orientation or Gender of Sex Partner(s) Make a Difference? Lisa L. Lindley, DrPH, MPH,

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STDs among Sexually Active Female College Students: Does Sexual Orientation or Gender of Sex Partner(s) Make a Difference? Lisa L. Lindley, DrPH, MPH, CHES Dept Health Promotion, Ed. & Behavior Arnold School of Public Health Michelle Burcin, PhD, MPH, CHES Director, Healthy Carolina University of South Carolina

Background College students, esp. females, at risk for STDs: Alcohol use, multiple sex partners (ACHA, 2007) Immature cervix (Moscicki, Shiboski & Broering, 1998; Ho et al., 1998) STD risk factors among lesbian and bisexual women: Older age, substance use/IDU, # sex partners, vaginal intercourse w/men, earlier age 1st same-sex experience. (Bailey et al., 2004; Carroll et al., 1997; Diamant, Lever & Shuster, 2000; Dolan & Davis, 2003; Marrazzo, 2000; Marrazzo et al., 1996, 2000, 2003, Lindley et al., In-press) Few studies: STD risk among college lesbian and bisexual women. (Lindley et al., 2003, In-press) Comparing STD risk by sexual orientation and gender of sex partners. (Bauer & Welles, 2001)

Purpose To determine risk for STDs (past school year) among sexually active female college students based on self-reported sexual orientation and gender of sex partner(s) (past year). Secondary analysis, National College Health Assessment (NCHA) (Spring 2006 data).

*Sexually active = 1+ sex partners (past year) NCHA Spring 2006 123 postsecondary institutions 117 used random sampling 92 web-based, 22 paper, 3 both 4 year (96.6%), public (61.5%) colleges/universities Total: 94,806 (Females: 57,903) N = 29,952 sexually active* non-international females *Sexually active = 1+ sex partners (past year) http://www.acha-ncha.org

Demographics Age Range: 18-24 years Mean Age: 20.4 yrs (SD=1.60) Race/Ethnicity: White 78.0% Black 4.9% Hispanic 5.5% Asian/PI 7.2% AI/AN 1.2% Other 3.1% Year in School

Measures: Sexual Orientation & Gender of Sex Partner(s) Which of the following best describes you? Heterosexual Gay/Lesbian Bisexual Transgendered (Not included in the analyses) Unsure Within the last school year, were your sexual partner(s), if any: N/A (Not included in the analyses) Male Female Both Male and Female

Table 1: Sexual Orientation, Gender & # Sex Partners (past year) % Heterosexual 28261 94.4 Gay/Lesbian 271 0.9 Bisexual 1000 3.3 Unsure 420 1.4 Gender of Sex Partners (past year) Male 28728 95.9 Female 615 2.1 Both Male and Female 609 2.0 Number of Sex Partners (past year) 1 partner 19479 65.0 2 partners 5173 17.3 3-5 partners 4394 14.7 6+ partners 906 3.0

Table 1: Sexual Orientation, Gender & # Sex Partners (past year) % Heterosexual 28261 94.4 Gay/Lesbian 271 0.9 Bisexual 1000 3.3 Unsure 420 1.4 Gender of Sex Partners (past year) Male 28728 95.9 Female 615 2.1 Both Male and Female 609 2.0 Number of Sex Partners (past year) 1 partner 19479 65.0 2 partners 5173 17.3 3-5 partners 4394 14.7 6+ partners 906 3.0 Had 2+ partners n % 9691 92.5 193 1.8 589 5.6

Table 2: Gender of Sex Partner(s) (past year) by Sexual Orientation Male (%) Female (%) Both Male & Female (%) Heterosexual 28261 98.4 0.9 0.6 Gay/Lesbian 271 4.8 84.9 10.3 Bisexual 1000 55.7 9.7 34.6 Unsure 420 81.0 5.5 13.6

Measures: STD Diagnosis (past year) Within the last school year, have you had any of the following: Chlamydia Genital herpes Genital warts/HPV Gonorrhea HIV infection STD Diagnosis = Diagnosed with one or more above.

Table 3: Percent reporting STD (past year) by Sexual Orientation HPV/ warts Chlamydia Genital Herpes Gonorrhea HIV 1+ STD Heterosexual 3.8 1.3 1.1 0.2 0.1 5.8 Gay/Lesbian 0.4 1.5 0.0 2.3 Bisexual 5.9 1.9 0.3 9.1 Unsure 5.0 0.7 1.2 6.3 Significance p<.001 NS

Table 4: Percent reporting STD (past year) by Gender of Sex Partner(s) (past year) HPV/ warts Chlamydia Genital Herpes Gonorrhea HIV 1+ STD Male 3.7 1.3 1.0 0.2 0.1 5.7 Female 3.3 0.3 1.5 4.4 Both Male & Female 10.1 0.7 15.3 Significance p<.001 NS

Table 5: Percent reporting STD (past year) by Gender of Sex Partner(s) (past year) (2+ partners) HPV/ warts Chlamydia Genital Herpes Gonorrhea HIV 1+ STD Male (2+) 5.4 2.4 1.2 0.4 0.1 8.7 Female (2+) 4.7 1.1 2.1 0.5 5.9 Both Male & Female 10.4 3.4 3.2 0.2 15.5 Significance p<.001 NS

Table 6: Number & Percent Ever Engaged in Oral, Vaginal and/or Anal Intercourse by Sexual Orientation & Gender of Sex Partner(s) (past year) Sexual Orientation Oral Sex N (%) Vaginal Int. Anal Int. Heterosexual 26516 (93.8) 25888 (91.6) 6282 (22.2) Gay/Lesbian 257 (94.8) ***198 (73.1) 87 (32.1) Bisexual **969 (96.9) 922 (92.2) ***434 (43.4) Unsure 394 (93.8) 373 (88.8) 140 (33.3) Gender of Partners Male 26960 (93.8) 26321 (91.6) 6483 (22.6) Female 579 (94.1) ***486 (79.0) 168 (27.3) Both Male & Female ***597 (98.0) 574 (91.4) ***292 (47.9) Overall 28136 (93.9) 27381 (91.4) 6943 (23.2) *p<.05; **p<.01; ***p<.001

Condom Last Vaginal Int. Table 7: Number & Percent Used Condom last Oral, Vaginal and/or Anal Intercourse by Sexual Orientation & Gender of Sex Partner(s) (past year) Sexual Orientation Condom Last Oral Sex N (%) Condom Last Vaginal Int. Condom Last Anal Int. Heterosexual 774 (3.0) 13471 (52.7) 1364 (23.2) Gay/Lesbian **13 (5.3) ***50 (26.7) 19 (26.4) Bisexual 24 (2.5) 457 (50.1) **126 (29.6) Unsure **20 (5.2) 203 (55.3) **40 (30.1) Gender of Partners Male 794 (3.0) 13694 (52.7) 1418 (23.3) Female 21 (3.7) ***189 (40.5) 38 (27.0) Both Male & Female 16 (2.7) 298 (52.3) **93 (32.5) Overall 831 (3.0) 14181 (52.5) 1549 (23.8) *p<.05; **p<.01; ***p<.001

Table 8: Mean Number of Sex Partner(s) (past year) by Sexual Orientation and Gender of Sex Partners Mean (SD) Overall 29952 1.8 (1.72) Sexual Orientation*** Heterosexual 28261 1.7 (1.53) Gay/Lesbian 271 2.0 (2.29) Bisexual 1000 2.8 (3.70) Unsure 420 2.5 (3.80) Gender of Partners*** Male 28728 1.7 (1.57) Female 615 1.7 (1.87) Both Male & Female 609 4.5 (4.19) ***p<.001

Table 8: Mean Number of Sex Partner(s) (past year) by Sexual Orientation and Gender of Sex Partners Mean (SD) Overall 29952 1.8 (1.72) Sexual Orientation*** Heterosexual 28261 1.7 (1.53) Gay/Lesbian 271 2.0 (2.29) Bisexual 1000 2.8 (3.70) Unsure 420 2.5 (3.80) Gender of Partners*** Male 28728 1.7 (1.57) Female 615 1.7 (1.87) Both Male & Female 609 4.5 (4.19) Had 2+ partners*** N Mean (SD) 9691 3.1 (2.07) 193 3.2 (2.78) 589 4.6 (4.79) ***p<.001

Table 9: Mean Number of Sex Partner(s) (past year) by Gender of Sex Partners (past year) among Bisexual College Women Gender of Partners*** N Mean (SD) Male 557 2.0 (2.72) Female 97 1.2 (0.62) Both Male & Female 346 4.6 (4.77) ***p<.001

Table 9: Mean Number of Sex Partner(s) (past year) by Gender of Sex Partners (past year) among Bisexual College Women Had 2+ partners*** Gender of Partners*** N Mean (SD) Male 557 2.0 (2.72) Female 97 1.2 (0.62) Both Male & Female 346 4.6 (4.77) N Mean (SD) 204 3.6 (3.98) 14 2.5 (0.88) 337 4.6 (4.79) ***p<.001

Table 10: Had a routine gynecological exam (past year) by Sexual Orientation and Gender of Partners % Heterosexual 28108 72.7 Gay/Lesbian 269 46.1 Bisexual 998 65.8 Unsure 418 64.1 Gender of Partners*** Male 28605 72.5 Female 580 54.0 Both Male and Female 608 73.2 ***p<.001

Table 11: Odds of STD diagnosis (past year) by Sexual Orientation OR (95% CI) Heterosexual 1.00 (Referent) Gay/Lesbian *0.38 (0.17, 0.85) Bisexual ***1.59 (1.27, 1.99) Unsure 1.12 (0.75, 1.66) ***4.24 (1.83, 9.79) *2.97 (1.21, 7.30) 0.70 (0.45, 1.10) *p<.05; **p<.01; ***p<.001

Table 11: Odds of STD diagnosis (past year) by Sexual Orientation Had Routine Gyn Exam Sexual Orientation OR (95% CI) Heterosexual 1.00 (Referent) Gay/Lesbian *0.38 (0.17, 0.85) Bisexual ***1.59 (1.27, 1.99) Unsure 1.12 (0.75, 1.66) ***4.24 (1.83, 9.79) *2.97 (1.21, 7.30) 0.70 (0.45, 1.10) OR (95% CI) 1.00 (Referent) *0.32 (0.10, 1.00) ***1.73 (1.37, 2.20) 1.01 (0.64, 1.59) **5.44 (1.69, 17.51) 3.16 (0.92, 10.84) *0.58 (0.35, 0.97) *p<.05; **p<.01; ***p<.001

Table 12: Odds of STD diagnosis (past year) by Gender of Sex Partner(s) (past year) OR (95% CI) Male 1.00 (Referent) Female 0.57 (0.17, 1.92) Both Male & Female ***3.64 (2.28, 5.83) **6.36 (1.94, 20.78) *p<.05; **p<.01; ***p<.001

Table 12: Odds of STD diagnosis (past year) by Gender of Sex Partner(s) (past year) Had 2+ partners Gender of Sex Partners OR (95% CI) Male 1.00 (Referent) Female 0.57 (0.17, 1.92) Both Male & Female ***3.64 (2.28, 5.83) **6.36 (1.94, 20.78) OR (95% CI) 1.00 (Referent) 0.66 (0.36, 1.23) ***1.92 (1.52, 2.44) **2.90 (1.51, 5.55) *p<.05; **p<.01; ***p<.001

Table 12: Odds of STD diagnosis (past year) by Gender of Sex Partner(s) (past year) Had 2+ partners 2+ part/gyn exam Gender of Sex Partners OR (95% CI) Male 1.00 (Referent) Female 0.57 (0.17, 1.92) Both Male & Female ***3.64 (2.28, 5.83) **6.36 (1.94, 20.78) OR (95% CI) 1.00 (Referent) 0.66 (0.36, 1.23) ***1.92 (1.52, 2.44) **2.90 (1.51, 5.55) OR (95% CI) 1.00 (Referent) 0.73 (0.35, 1.52) ***2.04 (1.59, 2.62) **2.78 (1.30, 5.96) *p<.05; **p<.01; ***p<.001

Discussion First large-scale national sample examining STD risk among sexually active female college students by SO and GoP. Bisexual women were at greatest risk for STD; gay/lesbian women were at least risk. However, lesbians (and WSW) were significantly less likely to have had a routine gynecological exam (past year). Equally important to note that not all bisexual students at high risk. Independent of sexual orientation, greatest STD risk was among women who had sex with both males and females (past year). 35% bisexual, 14% unsure, 10% gay/lesbian, and <1% heterosexual.

Limitations Cross-sectional data. Multiple data collection methods, especially web-based. Self-selection bias. Self-reported data: Sexual behaviors (with no definitions; e.g. “vaginal intercourse”) STD diagnoses (“had”/past year only) Coding scheme (sex w/males & females) created high-risk group. Is greater risk due to gender of partners, number of partners, or combination of both?

Implications Additional research needed to better understand sub-population of WSWM and factors associated with elevated risk taking. Vital that college and sexual health professionals understand difference between sexual orientation, identity and behavior. When assessing STD risk, focus on behaviors rather than identity or orientation. Educational efforts targeting lesbians/WSW must address behavioral risk for STD, safer sex practices, and importance of regular gynecological exams (Pap tests). Additional research needed to understand why young lesbians/ WSW do not seek routine gynecological exams.